1. Thermal Injuries: Burns NURS 225 Adult Nursing II 1

2. Objectives ▪ Compare the manifestations of superficial, partial thickness, and full thickness burn injuries. ▪ Prioritize nursing care for the patient during the resuscitation phase of burn injury. ▪ Prioritize nursing care for the patient during the acute phase of burn injury. 2

3. Classification of Burns ▪ Superficial: first degree ∙ epidermal layer ∙ causes: sunburn, ultraviolet light, minor flash injuries, mild radiation burns ∙ appearance: pink to bright red, slight edema ∙ mildly painful ∙ treatment: mild analgesia, water-soluble lotions 3

4. ▪ Partial-thickness: second degree ∙ dermis layer: superficial partial-thickness or deep partial-thickness burn ∙ causes: superficial - deep - ∙ appearance: superficial - bright red, moist deep – pale, waxy, moist or dry ∙ severe pain in response to air or heat ∙ treatment: analgesia, skin substitutes, grafting may be necessary 4

5. ▪ Full-thickness burns: third degree Deep full thickness: involves fascia and tissues, muscle, bone, and tendons ∙ causes: flames, steam, chemicals, high-voltage electrical current ∙ appearance: hard, dry, pale, waxy, yellow, brown, mottled, charred, or non-blanching red ∙ no sensation of pain or sensation of light touch ∙ treatment: requires skin grafting, amputation May be needed 5

6. Types of Burns Thermal ∙ dry heat- ∙ moist heat- Chemical ∙ acid – ∙ alkali – ∙ organic – Electrical ∙ severity dependent on type, duration, pathway, and resistance ∙ damage can be concealed/internal ∙ follows path of least resistance ∙ coagulation at site leads to necrosis ∙ direct current injuries have entrance and exit wounds Radiation ∙ therapeutic radiation – ∙ industrial radiation – 6

7. Rule of 9’s - determines extent of burn, percentage of body surface involved 7

8. Location of Burn Determines Extent of Injury Face, neck, chest  respiratory obstruction Hands, feet, joints, and eyes  self-care Ears, nose  infection Circumferential burns of the extremities can cause circulatory compromise and potential compartment syndrome 8

9. Pre-Hospital Management Stop burning process ∙ thermal burns – ∙ chemical burns – ∙ electrical burns – Support ∙ secure airway ∙ fluid replacement ∙ comfort ∙ prevent infection ∙ thermoregulation ∙ support circulation ∙ emotional support Transport - burn center criteria ∙ 55 burn centers in continental US ∙ University of Washington Burn Center - Seattle, Washington 9

10. Hospital Management Minor Burns ∙ skin remains intact - <15% split thickness, <2% full thickness ∙ excludes face/facial structures, hands, feet, perineum ∙ treatmentincludes: 10

11. Major Burns ~ Emergent Phase Fluid Resuscitation – three common resuscitation formulas Calculated *ml/kg/TBSA% (*ml/kg varies slightly among formulas) ∙ requires LARGE fluid loads over first 24 hours ∙ ½ of total fluid over 1st 8 hours after injury ∙ remainder of fluid given over the remaining 16 hours ∙ Goals – 30-50ml urine output/hr, SBP>90mmHg, P<120, RR 16-20 Fluid resuscitation formulas calculated from the time of INJURY not ARRIVAL at the hospital. 11

12. Fluid resuscitation example 70kg person, burn injury to head, left arm, left leg time of injury 8am – time of arrival at hospital 10am TBSA 36% ~ using Parkland Formula 4ml/kg/TBSA 4ml x 70 x 36 = 10080ml to be given over 1st 24hours 5040ml over 1st 8 hours = 630ml/hr (2050÷6=840ml/hr ~ 8 hours started at 8am) 5040ml over remaining 16 hours = 280ml/hr 12

13. Pathophysiology ∙ Integumentary ∙massive fluid loss through evaporation ∙heat loss ∙dependent on depth and severity of injury ∙no blood flow through damaged vessels ∙Bull’s eye appearance Goal = relieve pressure, restore blood flow, salvage ∙ Eschar – hard crust like, forms over necrotic skin 13

14. ∙ Cardiovascular ∙ hypovolemic shock ~ burn shock ∙ Fluid shift (3rd spacing) immediately after injury-24hours =intracellular -> intravascular -> interstitial ∙ ↑ permeability - ↑ intracellular edema - ↑ osmosis =profound weight gain, edema – Fluid remobilization-> diuresis 48-72 hours after injury ∙ normal loss - 30 to 50ml/hour ~ severely burned patient - 200 to 400ml/hour ∙ arrhythmia's ∙ TBSA >40% increased risk for arrhythmia's electrolyte shifts and cellular damage ∙ peripheral vascular alteration ~ compartment syndrome 14

15. ∙ Respiratory ∙ direct inhalation or systemic response ∙ inflammation ~ ∙ interstitial pulmonary edema ~ ∙ upper airway ~ ∙ smoke poisoning ~ ∙ CO poisoning ~ 15

16. ∙ Gastrointestinal ~dysfunction related to size of burn wound ∙ paralytic ileus- ∙ stress (curling’s) ulcers ~ ∙ ischemic bowel -> bacterial translocation -> sepsis -> multiple organ dysfunction ∙ Urinary ∙ early stages ~ ↓renal blood flow ->↓ GFR ∙ myoglobinuria ∙ progresses to renal failure 16

17. ∙ Immune System ~ open wounds and decreased immune function, infection and sepsis leading cause of death in acute phase local changes ∙ partial thickness -> full thickness ∙ ulceration of healthy tissue ∙ erythematous nodular lesions -> in uninvolved tissue ∙ vesicular lesions in healed tissue ∙ edematous tissue surrounding wound ∙ excessive drainage, odor ∙ pale, dry, crusted granulated tissue ∙ graft rejection ∙ dehiscence systemic changes ∙ changes in LOC ∙ subtle changes in VS (hemodynamic instability, hypoxemia) ∙ ↑ fluids to maintain adequate urine output ~ oliguria ∙ GI dysfunction ~ diarrhea, vomiting, ileus, distention ∙ hyperglycemia ∙ thrombocytopenia ∙ ↑ or ↓ WBC ∙ metabolic acidosis Monitor for organism related infection sepsis 17

18. ∙ Metabolism ~ heat and water loss increases metabolic and catabolic rates -> increase caloric needs -> resting metabolic rate ↑ 50% to 100% ∙ increased secretion ~ ∙ activated stress response ~ ∙ extent of injury dictates caloric needs ∙ increase in core body temperature 18

19. Treatment ~ three stages of treatment ∙ 1. Emergent – Resuscitative Stage ~ from injury through successful fluid resuscitation – 24 to 28 hours up to 5 days ∙ priority – detect/prevent ~ hypovolemic shock ∙ airway management - intubation ∙ limit extent of burn ∙ restore circulating volume ~ ↓ risk of burn shock, replace electrolytes, maintain adequate urine output ∙ large bore IV access ∙ cut down ∙ transfer to burn center if indicated and applicable 19

20. ∙ 2. Acute Phase ~ begins with diuresis (fluid shift) and ends with wound closure – wound are healed ∙ wound management ~ ∙ nutritional support – enteral/parenteral ∙ monitor for signs and symptoms of infection/prevent sepsis ∙ pain management ∙ monitor electrolytes ~ ∙ Na hyponatremia – hydrotherapy, GI drainage hypernatremia – hypertonic IV fluids, incorrect tube feeding ∙ K+hypokalemia – hydrotherapy, vomiting, diarrhea, GI suctioning, IV w/out replacement hyperkalemia – secondary to renal failure, adrenocorticoid insufficiency, massive deep tissue injury 20

21. 3. Rehabilitative stage ~ begins with wound closure up to and including restoration of optimal health status and function – may take years ∙ prevention of contractures and scars ∙ client returns to work, family, and social roles ∙ may include vocational, occupational, physical and psychosocial rehabilitation 21